By Jan Saunders, CPO, In-house Prosthetics/Orthotics Consultant, HomeCare Connect
Amputations in the work comp space are traumatic, costly and rare enough to require specialized managed care.
Often, prosthetic providers and manufacturers market directly to the patient and offer devices that do more than the person needs or is currently able to use. A treating prosthetist may discuss a sophisticated artificial limb with the injured worker before determining if they have the physical or cognitive abilities to use it. In one case, the provider prematurely promised a myoelectric arm, but subsequent tests showed that internal nerve damage prevented the residual limb from generating the muscle electrical signals needed to make the prosthesis work. Nothing is more disappointing to the injured worker than to be promised something that doesn’t come to fruition, and setting unrealistic expectations is a way to invite attorney involvement in the claim.
Early intervention from an expert Certified Prosthetist Orthotist (CPO) who has experience in workers’ compensation is the key to successful prosthetic outcomes. Ideally this prosthetist-consultant gets involved before the surgery and clinically manages the case to make sure the injured worker receives the right care, education and prosthesis from the start. This will reduce frustration and anxiety for the patient and improve overall outcomes.
This consultant reviews medical records, rehabilitation assessments and other clinical reports to ensure the recommended device is the best and most appropriate choice for the injured worker. The consulting prosthetist also advises the provider-prosthetist, cautioning the provider to thoroughly evaluate the injured worker and analyze the assessments and reports before recommending a device.
It’s a good idea to share clinical findings and prosthetic recommendations with the treatment and claims teams before discussing them with the injured worker. Holding a teleconference call with the adjuster, case manager and other stakeholders, such as the treating physician and physical therapists, if needed, enables the treating prosthetist to show the recommended limb, explain its function and costs, discuss the rational for selecting it, and answer questions. The consultant can address workers’ compensation issues, such as state fee schedules, medical necessity and appropriateness, and how the device can help the employee perform job duties.
Any of the stakeholders may need to be able to explain why a particular device was selected, and a video recording of this call may prove useful later in the claim. Also, getting stakeholders on the same page at the same time accelerates the approval processes.
Telehealth technology can also be used to help educate an injured worker on the features and use of the prosthesis. Plus, a live video conference may replace an office visit or two or facilitate a consultation with a specialist to resolve an issue.
The consulting CPO should also make sure that sound treatment protocol is in place and timelines are followed. For example, upon discharge, the injured worker should come home to appropriate nursing care, durable medical equipment and home modifications, and educational resources.
Timing is critical, and lag time is the enemy. Waiting for DME delivery or authorizations from the payer unnecessarily postpones treatment and recovery. If injured workers are not fitted with prosthetics as soon as they have been cleared after surgery, they become sedentary. When that happens, the residual limb may not achieve its optimal shape for the prosthetic, delaying the person’s ability to become ambulatory. An improper fit can also cause wounds and may require the purchase of multiple prosthetics in a short period of time.
Pricing prosthetics is tricky. The treating prosthetist’s quote should include a list of the components, their descriptions and corresponding HCPC L Codes. Few people understand what the thousands of prosthetic billing codes mean or how to determine if an estimate has been artificially inflated.
Unbundling and up-coding are frequently seen in these quotes. Unbundling refers to billing for individual components that already come with the device, such as the pads and straps on a neck brace. Up-coding can happen when a code for a specific component does not exist and an “other and unlisted code” is used. Other and unlisted codes typically end with 999 and essentially allow the seller to set any price desired for the item. A $2,000 component can become a $20,000 charge.
It takes someone who works with these codes on a daily basis to tell if the insurance carrier or other payer is receiving a fair, reasonable quote. Plus, when discrepancies are spotted, the consulting CPO can have a peer-to-peer dialog with the treating practitioner to clarify recommendations and correct issues.
Reserve setting takes on extra challenges when prosthetics are involved, and the consultant can be an excellent resource. First, “permanent” doesn’t mean lifetime. Residual limbs will continue to change throughout the injured worker’s life. Artificial limbs usually need to be replaced every three to five years, and sockets whenever documented physical changes are supported. Liners and other components sometimes give out earlier. The patient’s age, lifestyle, weight changes, job function, and care of the product will affect replacements. Taking all of these factors into account will help the client determine how money in reserves to set aside for the life of the claim.
Prosthetics are complex and expensive (the Amputee Coalition estimates five-year costs at $450,000 per person). Properly managing the care and cost involved takes more than just using a contracted provider or relying only on bill review. Optimum physical—and financial outcomes come from clinically managing the case from the start.
About Jan A. Saunders
Jan A. Saunders, a certified prosthetist and orthotist, manages HomeCare Connect’s orthotics and prosthetic services. Previously, he operated one of the largest prosthetics and orthotics companies in the United States. Saunders’ experience and expertise in the field span nearly 45 years. He began his career as a prosthetic technician before attending Northwestern University in Chicago and New York University in New York and later becoming board certified by the American Board of Orthotics and Prosthetics. Saunders’ areas of clinical expertise include all prosthetics and orthotics and he has a proven track record in business operations, clinical operations and profitability. Contact him at firstname.lastname@example.org.
About HomeCare Connect
Specializing in catastrophic cases, HomeCare Connect focuses exclusively on managing the quality and cost of home health, durable medical equipment and supplies and home modifications for workers’ compensation payers. With more than 17,000 contracted network providers, its services include nursing, home infusion, respiratory therapy, speech and occupational therapy, prosthetics and orthotics, and the coordination of DME and supplies along with managing home modifications. HomeCare Connect’s partners consolidated their 20-plus years of workers’ compensation experience into offerings and service standards that ensure that injured workers receive excellent care in the fastest time frames at the most affordable prices. HomeCare Connect guarantees response to referrals within two hours and the delivery of an initial medical summary within two days. Listed among the fastest growing, privately held companies in the Orlando, Florida region, HomeCare Connect serves clients nationally and can be reached at www.homecareconnect.com or 855-223-2228.
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This is not a paid placement.