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Medicare Coverage for Prosthetic Devices

Web Development Advocacy & Awareness

New Developments Require Action From Consumers

Most people think that once you become eligible for Medicare, all of the coverage and payment problems that are pervasive in the private health insurance industry magically disappear. But in fact, Medicare focuses significant energy on reducing inappropriate payments and overpayments to healthcare providers.

With this background, recent guidance from Medicare should be of interest to all amputees who are Medicare beneficiaries.

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The OIG Report

In 2011, the Office of the Inspector General published a report that summarized its review of payments made by Medicare to prosthetists of lower-limb prostheses. The OIG concluded that Medicare inappropriately paid $43 million for lower-limb prosthetic claims that did not meet the established requirements for payment, such as missing information about the patient’s ability to walk or prosthetic devices that were medically unnecessary because the patient’s functional level did not correspond to the device delivered. The OIG identified an additional $61 million in claims for patients who had no record of a visit with their referring physician in the previous 5 years.

Medicare, which was criticized by the OIG for not implementing appropriate safeguards to prevent these potentially inappropriate payments, reacted. Strongly.

Medicare’s Response

As a result of the OIG report, Medicare instructed the contractors who process all Medicare prosthetic claims to more closely scrutinize what prosthetists submit. In September 2011, these contractors sent out “Dear Physician” letters – letters to remind prescribing doctors of their responsibility to thoroughly document an amputee’s condition in their medical records. At the same time, various auditing entities that Medicare contracts with dramatically ramped up their reviews of lower-limb prosthetic claims.

Using this two-pronged approach, Medicare has taken the position that the doctor’s medical records – not your prosthetist’s – are the key documents when determining whether a patient can appropriately receive a lower-limb prosthesis. This leads to the following quandary: Your prosthetist delivers you a prosthesis, and his or her records documenting your need may be thorough, complete and objectively perfect; the doctor, however, may have failed to adequately document in his or her medical records that you are capable of walking at different speeds.

When auditing that claim, Medicare will take the position that because the physician’s record doesn’t corroborate the prosthetist’s, the payment that Medicare made for your prosthesis 6, 12 or 24 months ago was inappropriate. But since the doctor doesn’t get paid by Medicare – your prosthetist does – Medicare recovers the money from your prosthetist, whose records may be 100 percent accurate.

As a result, prosthetists have become increasingly concerned about delivering prosthetic devices to Medicare beneficiaries.

What does this mean for the consumer?

Many prosthetists have responded to these developments by insisting on seeing a copy of the doctors’ medical records before proceeding with the delivery of a prosthesis. This can result in delivery delays for Medicare beneficiaries. The Amputee Coalition has anecdotal evidence that some doctors simply refuse to provide the detailed information set forth in the “Dear Physician” letters because of the administrative burden it places on them, which forces patients to find new physicians who are willing to do the necessary paperwork. Some prosthetists are actively educating their patients about these requirements and having the patients go to their doctors to insist on appropriate documentation prior to delivery.

What can you do?

Be an informed and active consumer and help your prosthetist and doctor to get it right. The Amputee Coalition has developed a letter that outlines what documentation Medicare needs to have in the medical record to support payment for your prosthesis.

You can download this letter from our Web site, print it out and take it to your doctor when you go to get a prescription for a prosthetic device. This letter shows the doctor exactly what documentation Medicare is looking for in the medical record. Ask your doctor to be sure to read through this and to document your condition appropriately. This will help prevent claim denials and requests for repayment that could affect your relationship with your prosthetist.

Download letter that outlines what documentation Medicare needs at