responses to LCD lower limb prostheses
Eric Eisenberg
Description
Collection
Title:
responses to LCD lower limb prostheses
Creator:
Eric Eisenberg
Date:
1/25/2013
Text:
Original post:
Dear List,
Reading the CMS Local Coverage Determination (LCD) for Lower Limb Prostheses (L11442) under the section titled Medical record Information (PIM 5.7-5.9) it would appear physician owned practices are taking a huge financial risk. The LCD states Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary.
Isn't a physician who owns a prosthetic and orthotic practice to which he refers patients a healthcare professional with a financial interest in the claim outcome? These physicians are using there own prescriptions and clinic notes to justify prostheses for which they have a direct financial interest.
Since these physicians in these scenarios have now become our competitors is there something that can be done? As we as an industry are coming under greater and greater scrutiny for documentation by auditors seems based on the LCD the auditors could recoup ALL the money from physician owned practices. What do you all think??
Eric S. Eisenberg M.S.;C.P.O.
BioTech limb and Brace LLC
Replies:
-I agree you have a point if they are the only substantiating source, but I also read that our notes are not sufficient which is inconsistent with prior appeal findings.
-Hi, Eric,
Our feeling here is that with Medicare in the financial condition it is, they are going to do everything they can to find ways to not pay for care. One thing we have thought about doing, but have not yet implemented, is sending every amputee to a physiatrist for evaluation and K-level determination. We have had about the same success as everyone else seems to in having the referring physicians, usually surgeons, write acceptable notes for Medicare. In the scenario you describe, I agree that the conflict of interest exists, although it is clearly directed primarily at prosthetists, but they could do the same thing. That won't help them for things already done, but they would not necessarily have to divest themselves of the P&O part of their practice, although I would suspect that even with an outside evaluation, they will still be under greater scrutiny because of the potential conflict of interest with a cross-referral partnership. There is no doubt that they are at risk of full recoupment.
-Do you know about the Stark law? <URL Redacted>
-Maybe not all money, and certainly not because they are potential
competitors.
-That would make way too much sense Eric. The physicians seem to get away with everything and are never scrutinized! Likely because they have a very rich and powerful lobby!
-Mr. Eisenberg,
Anyone can make a copy of your post and it may be spread outside the O and P world.Please be careful for your own financial sake. -Eric, I think you are on to something here. Nice work. Our folks will be
taking a look at this as well. You will be seeing a list of federal
contracts, including the amounts awarded very soon. Hopefully, yet
today. There are some interesting observations there as well. Thanks for
the notice. -It is my understanding physicians who own O&P clinics cannot refer or write
prescriptions for patients who go the their clinic. All referrals have to
come from a physician who is not affiliated with the clinic. Starks Law
prohibits this...yes there are grey areas. Such as, how is a doc owning an
O&P clinic different from a doc selling a knee brace out of his office?
That's allowed as long as the doc takes ownership of the item and bills the
item him/herself. I don't like the idea of it...but it's a problem that has
been growing in my area for the last 5 or so years. We even have a hospital
who bought my competitors O&P business. So of course, when a patient has an
amputation where to they go?...the hospital send them to the facility they
own. Where's the choice for the patient..and why isn't that a conflict of
interest for the hospital system? I couldn't find the news article about
it..but I did find an ad where the hospital if looking for an orthotic
fitter.
<URL Redacted>
utm_campaign=Indeed -Greetings Eric........some years ago I knew of doctors who had interests in
Nursing Homes, but I've never known a Doc. to have interest in any P and O
clinic in my area...are you saying there are physicians who own a P & O in
your area??.......unfortunately many doctors have been are competitors for
years.... and I personally don't see where that is ever going to
change..........Have a great day...... -Please post that on speak4oandp.com -I am one who believes in relationships. Why not try to charm the auditors and see if you can get past the lower level and talk bluntly with them? Tell them how we all beat them at the ALJ level and realize that they work on a commission (ok, fine, it is what it is). Tell them that you would be happy to help them recognize these situations and filter out the ones that they will inevitably lose later. In this fashion, they spend more time on the ones that will make them money and wrap up the legit ones at a lower, less expensive, level? I respond to my own greed. I figure that others will too.
Good luck!
Hope all is well!
Dear List,
Reading the CMS Local Coverage Determination (LCD) for Lower Limb Prostheses (L11442) under the section titled Medical record Information (PIM 5.7-5.9) it would appear physician owned practices are taking a huge financial risk. The LCD states Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary.
Isn't a physician who owns a prosthetic and orthotic practice to which he refers patients a healthcare professional with a financial interest in the claim outcome? These physicians are using there own prescriptions and clinic notes to justify prostheses for which they have a direct financial interest.
Since these physicians in these scenarios have now become our competitors is there something that can be done? As we as an industry are coming under greater and greater scrutiny for documentation by auditors seems based on the LCD the auditors could recoup ALL the money from physician owned practices. What do you all think??
Eric S. Eisenberg M.S.;C.P.O.
BioTech limb and Brace LLC
Replies:
-I agree you have a point if they are the only substantiating source, but I also read that our notes are not sufficient which is inconsistent with prior appeal findings.
-Hi, Eric,
Our feeling here is that with Medicare in the financial condition it is, they are going to do everything they can to find ways to not pay for care. One thing we have thought about doing, but have not yet implemented, is sending every amputee to a physiatrist for evaluation and K-level determination. We have had about the same success as everyone else seems to in having the referring physicians, usually surgeons, write acceptable notes for Medicare. In the scenario you describe, I agree that the conflict of interest exists, although it is clearly directed primarily at prosthetists, but they could do the same thing. That won't help them for things already done, but they would not necessarily have to divest themselves of the P&O part of their practice, although I would suspect that even with an outside evaluation, they will still be under greater scrutiny because of the potential conflict of interest with a cross-referral partnership. There is no doubt that they are at risk of full recoupment.
-Do you know about the Stark law? <URL Redacted>
-Maybe not all money, and certainly not because they are potential
competitors.
-That would make way too much sense Eric. The physicians seem to get away with everything and are never scrutinized! Likely because they have a very rich and powerful lobby!
-Mr. Eisenberg,
Anyone can make a copy of your post and it may be spread outside the O and P world.Please be careful for your own financial sake. -Eric, I think you are on to something here. Nice work. Our folks will be
taking a look at this as well. You will be seeing a list of federal
contracts, including the amounts awarded very soon. Hopefully, yet
today. There are some interesting observations there as well. Thanks for
the notice. -It is my understanding physicians who own O&P clinics cannot refer or write
prescriptions for patients who go the their clinic. All referrals have to
come from a physician who is not affiliated with the clinic. Starks Law
prohibits this...yes there are grey areas. Such as, how is a doc owning an
O&P clinic different from a doc selling a knee brace out of his office?
That's allowed as long as the doc takes ownership of the item and bills the
item him/herself. I don't like the idea of it...but it's a problem that has
been growing in my area for the last 5 or so years. We even have a hospital
who bought my competitors O&P business. So of course, when a patient has an
amputation where to they go?...the hospital send them to the facility they
own. Where's the choice for the patient..and why isn't that a conflict of
interest for the hospital system? I couldn't find the news article about
it..but I did find an ad where the hospital if looking for an orthotic
fitter.
<URL Redacted>
utm_campaign=Indeed -Greetings Eric........some years ago I knew of doctors who had interests in
Nursing Homes, but I've never known a Doc. to have interest in any P and O
clinic in my area...are you saying there are physicians who own a P & O in
your area??.......unfortunately many doctors have been are competitors for
years.... and I personally don't see where that is ever going to
change..........Have a great day...... -Please post that on speak4oandp.com -I am one who believes in relationships. Why not try to charm the auditors and see if you can get past the lower level and talk bluntly with them? Tell them how we all beat them at the ALJ level and realize that they work on a commission (ok, fine, it is what it is). Tell them that you would be happy to help them recognize these situations and filter out the ones that they will inevitably lose later. In this fashion, they spend more time on the ones that will make them money and wrap up the legit ones at a lower, less expensive, level? I respond to my own greed. I figure that others will too.
Good luck!
Hope all is well!
Citation
Eric Eisenberg, “responses to LCD lower limb prostheses,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/234581.
