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05/19/2023 Paul Kesselman, DPM
CA Podiatrist Discusses How to Get Insurance to Cover AFOs (Ed Davis, DPM)
Dr. Davis brings up some very interesting points, all of which have been discussed ad nauseum for more than a decade. There have been innumerable meetings with every health care professional organization involved in providing all orthotic devices affected by this policy. I have attended countless meetings and discussion groups with these organizations and CMS. Long before that a significant number of examples of how this broken policy is counterintuitive to patient outcomes was presented to the DME MAC and eventually to CMS were discussed.
The problem with the absurd five-year same or similar rule, does not square solely with the DME MAC, but with language contained in the Social Security Act and the absolute unwillingness of CMS to change that language. Barking at the DME MAC and their policy writers and the DME MAC medical directors is literally barking up the wrong tree! The DME MAC teams are the dog’s tail while the head of the dog is CMS! Currently, there is a work around https://med.noridianmedicare.com/web/jddme/policies /dmd-articles/2020/same-or-similar-denials-for- orthoses-and-the-appeals-process
with the DME MAC Medical Director’s providing a jointly issued paper in late Summer 2022 which provides a road map for documenting the replacement of an existing device.
1) I have found that using that document as the basis for one’s charting for replacing a device, no matter whether for a different/replacement device for the same or different diagnosis or condition in over 90% of the cases results in successful appeals.
The other option is to have the patient sign an ABN and have them pay for the new device. While this may not be popular or even possible for many providers to practically obtain, it nevertheless does exist.
2) The review process by the RAC and other agencies is no doubt flawed. But this is not limited to DME and is due to the bounty hunter payment system. This needs to be fixed!
Long-term, there is pending legislation which has the potential to resolve the same or similar problem. If passed, this would change the language in the Social Security Act and provide relief to every health care provider effected by this myopic policy. Podiatrists are not in this alone as the current state affects every supplier of orthotic devices including but not limited to spinal, dental, upper extremity, etc.
All of this and more was discussed during the recently concluded APMA Committee meetings in Bethesda last week.
To allude that this is a podiatry problem alone or that medical associations are not working hard enough to resolve this issue is clearly wrong!
I can’t disagree with Dr. Davis, in his assertion that there are simply too many hoops to go through. Furthermore, “Patients over Paperwork” is clearly a misnomer.
There is much more to comment on this issue, which will be included in a full-length feature article in an upcoming issue of Podiatry Management.
paul Kesselman, DPM, Oceanside, NY
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