BY Jan Saunders, CPO, Orthotics and Prosthetics Director, HomeCare Connect
Amputations are the costliest injuries in workers’ comp, according to the 2016 Travelers Injury Impact Report, with five-year prosthetic costs estimated at $450,000 per person by the Amputee Coalition. Care-driven cost containment relies on specialized prosthetic and orthotic (P&O) providers who can select the most appropriate prosthesis, educate the injured employee on its use and guide the recovery process. Specialized utilization review is the second key to optimizing savings.
Eliminating lag times for the initial clinical assessment and authorization optimizes recovery and cost. When an amputee has to wait weeks for an evaluation or authorization, he/she becomes more sedentary and the limb loses its optimal shape. Then, the injured employee has to spend more time with a shrinker, which extends disability and adds indemnity costs.
Recent amputees should be seen within a week after the treating physician orders a prosthetic evaluation. And, the payer should expect to receive a comprehensive quote within two to five business days post assessment and be able to authorize P&O services in five to seven days. Administrative delays drive costs unnecessarily.
About the Quote
To facilitate an informed decision, payers can require that a quote includes:
- Determination of medical necessity
- The referring physician’s medical records and all clinical notations;
- The complete prosthetic assessment, including the clinical assessment;
- Results of the objective tests used to determine ambulation levels and functional capacity
- The prosthetic manufacturer
- A list of the parts and their descriptions and HCPC L codes
It’s unrealistic to expect adjusters and case managers to understand the nuances of prosthetic pricing, so it’s a good idea to work with a specialized P&O reviewer. There are thousands of prosthetic HCPC billing codes for prosthetics and it takes someone who works with them day in and day out to know if a similar product and code would work just as well.
The quote and supporting documents should be examined for medical necessity and clinical appropriateness and undergo fiscal analysis. Peer-to-peer review can probe questions about coding, bundling and up-charging to make sure the injured worker is receiving the most appropriate prosthetic in the most cost-effective manner. In some cases, a knowledgeable case worker should visit or call the injured employee to make sure the recommended prosthetic meets his/her needs. This review should be performed by an individual or firm with deep expertise in both prosthetics and workers’ compensation.
A specialized reviewer can also negotiate the best price on a recommended component. The stakes are high and quotes on similar components can vary dramatically. Plus, if a P&O provider quotes 10 percent off Medicare’s fee schedule, and the reviewer may be able to get 20 percent. Some quotes are based on usual and customary charges instead of Medicare and the difference can be a $30,000 missed savings on a single limb. This is especially true with some of the high-end components used in comp that are not allowable by Medicare and therefore not on a fee schedule. It takes an experienced P&O reviewer to negotiate a fair price.
Amputations are catastrophic events for injured employees and payers alike. These injured employees deserve proactive care from expert providers who will maximize their mobility to fit their lifestyles and workplace needs. Payers need help from specialized bill review vendors that can optimize savings, while ensuring quality care and the best prosthetic for the injured person. Timely appointments, proactive care and fast approvals make all the difference.
About Jan Saunders
Jan A. Saunders, a certified prosthetist and orthotist, manages HomeCare Connect’s orthotics and prosthetic services. Saunders’ experience and expertise in the field span 43 years. He began his career as a prosthetic technician before attending Northwestern University in Chicago and later becoming board certified by the American Board of Orthotics and Prosthetics. Saunders’ areas of clinical expertise include all prosthetics and scoliosis bracing. He has a proven track record in business operations, clinical operations and profitability and is also the senior vice president and Chief Clinical Officer for Orthotics and Prosthetics by Design. Previously, Saunders owned and operated his own company with 14 offices and later sold it to a publicly traded company. Contact him at firstname.lastname@example.org.
About HomeCare Connect
HomeCare Connect is a national ancillary network focused on workers’ compensation and providing home health, durable medical equipment, home modification, and orthotics/prosthetic services. Orthotic and prosthetic services include a credentialed, national network of credentialed providers, a specialized account team, and clinical quality review conducted prior to invoicing to determine consistent coding and eliminate any double billing, up-coding or unbundling. The privately held company has a clinically driven model — from its 17,000+ credentialed provider network — to its highly experienced clinical staff who coordinate everything related to care, medical supplies and equipment delivered in the home. HomeCare Connect ensures the injured employee receives the right care, equipment and supplies from the right providers at the right time. The company can be reached at www.homecareconnect.com or 855-223-2228.