same similar and Medicare

same similar and Medicare

Jim Del Bianco

6/18/2020

List,

I hope everyone is doing as best as they can! Tough times for sure.

I want to find out if the same/similar issue is being experienced across
all regions. Let me share what I have seen in Region C (I assume
everyone in Region C is having the same experience.)

I would like to have some positive discussions with Medicare or Congress
Representatives in an attempt to rectify this situation. Really it is only
a part of a much broader problem related to the Program Integrity Manual
and the way the manual has been expressed in the LCDs and then is used by
RAC, ZIPC, and other auditors to determine medical necessity. That
determination is something no one can check before delivery and the quality
of the language auditors are looking for is at the level a lawyer would be
expected to deliver in a courtroom. That is just simply not practical in a
clinical setting.

I am still operating under the assumption this is MCRs best attempt to
limit fraud, and MCR DMEMACS are doing the best they can to apply what they
are reading in the Program Integrity Manual and the LCDs. Perhaps, if we
listen to one another we can both fight fraud and relieve some of the
burden on providers.

So here in region C it would seem CGS (the DMEMAC for this region) has a
system that automatically denies any AFO, KAFO, KO, and TLSO when a same/or
similar device has been provided within 5 years, the determined RUL for
orthoses. There is a list of codes considered similar and you can look
online to find out if the Pt has had a device in the last 5 years. That is
very helpful and an improvement over previous years. So we know ahead of
time it is an issue and we work with the Pts doctor to get very detailed
notes to justify the new device.

Early last year when this started we passed a few audits with notes stating
the Pt's condition changed etc. Then they all began denying. We thought
maybe our notes needed to be better. We did better and they still denied
almost 100% of the time. This year we had doctor's (which they hate) add
several very detailed paragraphs on the changes in condition that justified
the new device. I now have all the audits back for a group of 4 patients
for whom we have the most fantastic, detailed notes I could imagine. They
are so good the doctors may never refer to us again after helping us with
the notes. Ha ha! All the claims denied stating the records were
insufficient to justify a change.

So, is this the experience nationwide? If so, let me know if you would like
to help me understand how to make a change here. I need to figure out who
exactly at Medicare to discuss this with. I think changes to the program
integrity manual will take congress.

These issues have been ongoing since the dear doc letter about prosthetics
some years ago. Same issue really. I assume AOPA and other organizations
have spent time on this which likely means it is near impossible to change.
I nonetheless feel we must try.

I would also ask practitioners who don't own businesses to take this
seriously. We need to come together and work toward this. I have often been
concerned that we were successful in creating a master's program but we
have had zero success in winning battles that correlate with increased fee
schedules or improved coverage or decreased administrative burdens. Wins in
those categories are a must in order to pay practitioners more across the
board. I want to cry when I see an amazing resident with over a 100K in
debt for an O&P degree, and yet there has been an almost completely flat or
negative situation in reimbursement. We need to fight these battles. The
masters program was hailed by many as being the first step to being treated
more professionally, but it seems we have stopped there and not pushed
equally hard for critical changes that need to take place to support the
higher level of education required to enter the field.

I am sure our AOPA and NAAOP have worked hard on these. We need to add more
support since, from what I can tell, no measurable gains have been made
that correlate to any kind of relief. I will get started on my end.

1. Can anyone provide meaningful Medicare or congressional contacts to
communicate with?
2. I had a Pt whose items denied that was so upset she wrote a letter to
Medicare and to her congress rep. Can we get 100s of these sent to
Medicare? I could collect them and send a cover letter requesting a meeting
to discuss ways to fight fraud and abuse without hurting honest providers.
3. Have your Pts call Medicare and complain about the rules for same and
similar devices. They can state they feel their access to care is being
limited by these restrictions.
4. Everyone can start calling Medicare to discuss this issue. I really
think we would eventually get an audience to discuss solutions with them.

On one hand I am excited to work toward improvements, on the other hand I
want to laugh at myself to think anyone will care or listen at Medicare or
Congress. I realize they have many tough tasks and money is limited. I just
feel there is a better way than to allow us to provide things based on our
best reading of the LCDs and then take money back. I am fine if they want
to disagree up front or maybe cover less if they have no choice from a
dollars point of view, but not to tell us we can do it and then take it
back when we disagree about the quality of a doc note.

--
Jim Del Bianco cpo nc