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05/18/2023 Ed Davis, DPM
CA Podiatrist Discusses How to Get Insurance to Cover AFOs (Paull Kesselman, DPM)
Many thanks to Dr. Richie and Dr. Kesselman for their efforts to enable podiatrists to prescribe AFOs to Medicare patients. This is a necessary and important service to improve the lives of many patients who have restricted mobility due to malfunction of the foot and ankle.
The reimbursement process has been, at times, a tortuous one. The documentation and forms required to demonstrate need for AFOs and document proper device delivery are available on the websites of many podiatric orthotic labs. Difficulties with reimbursement persist despite following the rules for documentation.
Here are some of the challenges. 1.Incorrect interpretation by DMERC Medicare carriers of the "same and similar" rule. DMERC will not pay for an AFO of the same or similar type in a 5 year period after dispensation. What does similar mean? If a patient has lateral ankle instability and presents to the office with an acute sprain, we are obligated to provide acute care. That may mean an ankle brace, CAM walking boot or possibly a cast, depending on severity. Once the acute phase is over and the sprain is healed, the patient still has lateral ankle instability. That may be effectively treated with an AFO. Provisioning of a custom AFO for lateral ankle instability involves a device that is by no means "same or similar" to the device used for the acute injury. Nevertheless, DMERC will likely not allow the AFO under the rule. This needs to be fixed. I feel that it can only be fixed by creation of a list of devices that are not same or similar based on medical standards of care and have Medicare/DMERC agree to that list. Yes, this is a challenge, but without such an agreement, the issue will persist.
2. Flawed review process. I have had AFOs, in several cases that were paid by Cigna, our regional DMERC carrier, only to be recouped three years later. Cigna sends a letter stating that a Recovery Audit Contractor (RAC) did a review and decided that the devices were not medically necessary and demands recoupment. We then ask how that was determined. Cigna replies that the Recovery Audit Contractor sent us a letter requesting additional information. We have never received such letters. Cigna then justifies their recoupment action on the incorrect assertion that we failed to answer the non-existent RAC letter. We appeal. Cigna then asserts that we did not appeal in a timely fashion, despite appealing within days, and rejects the appeal. The DMERC carriers are well aware that most offices can be discouraged from utilizing AFOs by utilizing a process that is sufficiently tortuous to deter solo practitioners with limited resources.
Ed Davis, DPM, San Antonio, TX
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