Volume 2, 2002

First Step - A Guide for Adapting to Limb Loss, A publication of the National Limb Loss Information Center

Prosthetic Costs

image: doctors with patientby Jon B. Holmes, PT, CP

It always amazes me when new patients come into my office and say, “I want the best leg there is and I do not care how much it costs.” They seem to have the idea that the most expensive prosthesis will be the best one for them. I guess that is some sort of “American logic.” In this age of so many prosthetic choices, it is hard to figure out what is best for each individual - but it certainly is not necessarily the most expensive prosthesis.

I have seen invoices in our company’s archives for complete below-knee prostheses for $150. There were no prosthetic choices given to the consumers; they paid cash for their leg and would often tell me all the wonderful things they were able to do with it. This is no longer the case. Patients now come into our office with all this literature they have printed from the Internet and want a prosthesis just like the one they saw on television. Then they present us with their insurance card, telling us it will pay for whatever they want. This also is not usually the case. So how do we figure out what is best for each individual?

The cost of a new prosthesis can be a staggering amount and is often a factor in the kind of prosthesis the consumer will get. Your doctor or surgeon, a comprehensive amputee clinic, your therapist, your social worker, and a certified prosthetist are best suited to help you with the choice and to show you how to maximize your investment and realize your ultimate potential with your new prosthesis. At this point, you should conduct a preliminary check of how you are going to pay for your prosthesis. If you have insurance, verify that there is prosthetic coverage and what the coverage is. It is important to have a professional help with this. A rehabilitation nurse, a social worker, or an insurance expert at a prosthetic company would be good choices. Insurance wording can be confusing and it is easy to make assumptions based on generalities in your policy. Often the insurance company has prosthetic coverage, but will only pay for a prosthesis once, has specific exclusions, or will only pay a certain amount. Without checking the specifics, it is easy to make poor choices. How your policy reads can help determine what is the best prosthesis for you.

image: doctor and patient looking at prosthetic optionsIf you do not have insurance, it is just as important to think about how you will pay for your prosthesis. There are state agencies that can be helpful, but lots of paperwork is involved, so get started early. Local charities are often a source of funding, but there is usually no organized process to obtain this money. It will require a lot of work to identify these groups, make the appropriate contacts, and get the assistance. In addition, some prosthetic firms will be willing to work out payment arrangements for limbs. The Barr Foundation in Boca Raton, Florida, helps people pay for prostheses when they are unable to get funding any other way (call 561/394-6514).

Start by considering your needs from your body and work from there. The most important part of the prosthesis is “the motor” (the amputee). Spend your time and energy getting your body in the best condition possible before moving on. To use a prosthesis effectively, your body must be well-healed, have a good range of motion, be strong, and have good balance. Investing in a prosthesis before you are physically and mentally ready is not the most economical way. The prosthesis is a tool to help you with your rehabilitation not a cure-all. Engage a good physical therapist to help you with this.

When determining your prosthetic needs you may have to choose between a temporary prosthesis and a definitive one. Knowing how much your insurance will cover can be helpful in this situation. If your insurance is going to pay for only one prosthesis, this might be a factor in making your decision. If you still expect many body changes, a temporary prosthesis may be in order. It will allow you to get more prepared for the definitive prosthesis and even help you figure out which components might be best. A definitive prosthesis, anticipating socket changes, can be a good choice for someone who is ready to be fitted. Then, when you get your training with your new prosthesis, you are learning to use the components best suited for your needs. This can save going back later for more training when you move on from a temporary to a definitive prosthesis. Once again, which is more cost-effective is an individual decision. The amputee clinic team will be the best people to assist you with this difficult choice.

The interface between the body and the prosthesis, known as the socket, should be the next thing to consider. This intimate part of the prosthesis will need to be customized for your individual needs. A well-fitting socket will provide comfort, suspension, and control of the prosthesis. Special needs because of scars, unique body proportions, muscle function, and other physical characteristics must all be considered when deciding which type of socket is best for you. Choices will not be the same for everyone. The certified prosthetist will be able to give you direction. Rarely will insurance companies dictate your socket choices, as they also recognize that without a well-fitting socket interface the prosthesis will not be used to its fullest potential.

image: patient meeting in hospital roomUsing the HCFA (Medicare) classification system is a good way to begin considering your choices for knees and feet. Being placed into a specific K-level classification will begin narrowing your options (See K-Level Classifications on page 86). Certain components are appropriate for each individual level; however, these guidelines will only be generalities and will not help you select specific brands. This will be your most difficult choice. Hundreds of different feet and knees are on the market, and advertising will lead you to believe each one is the best. You must rely on professionals and your peers for advice, remembering that even these people will have their own biases. Often after you have made your general choices, various components can be tried to see which one is best for you. Many manufacturers will allow a “free trial period” allowing amputees to compare components before deciding which ones they prefer. The correct knee and foot will allow greater prosthetic efficiency for each individual. Specialty devices like shock absorbers, rotators, torque absorbers, swimming ankles, quick-change devices, and numerous other components can make the prosthesis function better. Though these devices may not be covered by insurance, they could be worth the additional expense. These devices have their drawbacks, too, since they take up a lot of room, add weight, require more maintenance, and increase costs.

After an exact prescription has been made for a new prosthesis, insurance preapproval must be obtained. It is not enough that you verified your coverage in the beginning. The insurance company must now authorize the new prosthesis with every detail accounted for. Only the prosthetic firm where the prosthesis is made should do this. Be prepared to make appeals and justify the exact components selected. Often the insurance company will deny specific components as not enhancing the “fit or function” of the prosthesis. Be prepared to get letters of medical necessity from your doctor and make phone calls to the appropriate people to get what you need. Payment is the patient’s responsibility and you will have to work to maximize your benefits.

Obtaining the best possible prosthesis (especially a first one) is not a simple matter. It will require lots of energy. This will include putting together a good support team, getting your mind and body prepared, and obtaining funding. The amputee is forced to deal with these challenges. But if this process is under-taken with care and understanding, you will be an informed prosthetic consumer who is pleased with your prosthetic choices.

For more information on funding sources, call the Amputee Coalition toll-free at 1-888/AMP-KNOW (267-5669).

Author: Jon B. Holmes, PT, CPAbout the Author:

J on B. Holmes PT, CP, has worked at Muilenburg Prosthetics and Orthotics for nearly 17 years. He is currently the clinical director at Muilenburg’s, adjunct faculty at Texas Woman’s University, and associate professor at Baylor College of Medicine in Houston, Texas.

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