By Jan A. Saunders, CPO, LPO, In House Clinical Director of Prosthetics & Orthotics, HomeCare Connect
When a work injury results in an amputation, payers need to act quickly. Early intervention, counseling and education, and delivering the right care – especially the right prosthesis – at the right time dramatically improve outcomes and reduce costs.
A Certified Prosthetist Orthotist (CPO) employed by a managed care company–one who is not compensated by a prosthetic manufacturer or practice–should conduct a prosthetic pre-assessment consultation with the injured worker prior to discharge after surgery. It’s even better if this occurs before the surgery.
This CPO reviews medical records, rehabilitation assessments and other clinical reports, explores the individual’s lifestyle, hobbies, occupational tasks and probes for any psychosocial issues.
An amputation is a traumatic, life-changing experience and these injured workers are prone to feelings of perceived injustice, depression, anger, and fear. Some think their lives are over, especially if they are the main breadwinners and believe they can no longer work. The CPO encourages the workers to vent and explore their feelings while educating them on what to expect in terms of recovery. The goal is to help them think positively about their ability to resume the hobbies and activities they enjoyed prior to the injury.
Injured workers need to realize that they will be able return to society and function in everyday lives after an amputation. In most cases, they can also return to work. Hearing about other amputees, like a military pilot with a below-the-knee amputation who is still able to fly planes or the man who lost his arm in work-related injury yet continues his hobby of racing cars, brings hope and motivation.
The independent managed care CPO provides the pre-assessment results to the treating prosthetist, who then conducts a thorough clinical evaluation before a prothesis is recommended a peer-to-peer review is conducted to ensure appropriate care is provided. Then the CPO oversees the case, making sure that sound treatment protocols are in place, psychosocial issues are addressed, timelines are followed, the most appropriate prosthetic is selected, and that bills are fair and accurate.
Ensuring the injured worker has everything they need to recover after surgery and prepare the residual limb for a prosthetic, starts early as well. Claims representatives and employers need to understand the prosthetic process so they can best manage these cases.
Naturally recovery timelines vary according to the severity of the injury, the overall health of the injured worker and any co-morbidities or psychosocial impediments along with how well (and how early) the case is managed. The following timeline applies to an otherwise healthy, 25-year old injured worker with an above-the-knee amputation who is receiving early, proactive and appropriate care. In other words, this is a best-case scenario from surgery to delivery of the prosthesis.
- Week 1 post surgery – Start using compression garment (shrinker) to reduce initial swelling. The shrinker needs to be worn for 2 weeks.
- Week 2 post surgery – Sutures come out. First casting to be fit for clear diagnostic check socket. Manufacturing of socket takes about a week.
- Week 3 post surgery – Fit injured worker with first clear diagnostic check socket. Injured worker learns to walk within parallel bars wearing the socket with full components.
- Week 4 – Make any adjustments and recast the socket (unless the first was a perfect fit). 1 week to manufacture.
- Week 6-7 – Deliver the prosthesis and ensure proper fit and education is completed.
While in the hospital after surgery, injured workers receive safety therapy from a physical therapist or occupational therapist to prepare them for the transition home. Below-the-knee amputations should also have a limb guard, a device that places ample padding against the residual limb and is held in place with hard plastic and Velcro. The plastic and padding take the impact if the person falls.
And, falls are common because the nerves from the foot to the brain are still intact in a new amputee and they sometimes forget they don’t have the leg until they try to put weight on it. An unprotected fall can cause a re-injury that may require surgery and delay care by three or four months, so a roughly $500 investment in a limb guard can avoid $70,000 or more in costs.
Once home, they need home health nursing care for two to four weeks along with physical therapy and/or occupational therapy services. Most amputees need a minimum of eight weeks of physical/occupational therapy, approximately four weeks before receiving prosthesis and four weeks after. Some of this therapy can be delivered in clinics instead of at home.
Durable medical equipment (DME) is also required. Most lower extremity amputees need a temporary bedside commode, grab bar, slide bar, and ramp. Note the emphasis on temporary. While injured workers with lower extremity prosthetics will probably always need crutches and maybe a walker, with the right prosthesis, most can learn to navigate stairways and other household barriers.
The right prosthesis for the injured worker’s lifestyle, work environment and condition is critical. Some manufacturers and prosthetic providers (without authorization) contact injured workers to market sophisticated, extremely expensive prosthetics – whether or not the device will work for the injured worker’s condition.
For example, an injured worker was scheduled to receive $200,000 worth of legs with microprocessors until an independent managed care CPO was brought into the claim. Watching video of a physical therapy session, he saw that it took two therapists to lift the man into a standing position and then it required too much exertion for him to use the legs. (Walking with a prosthesis requires significantly more energy than walking on two legs.)
Without intervention, the carrier/employer would have paid for microprocessor legs that would probably end up sitting in a wheel chair.
One of big cost drivers, though, is lag time — delayed authorizations for services and equipment. If not fitted for the prosthesis as soon as they have been cleared after surgery, injured workers become sedentary and need more rehabilitation time. The residual limb loses optimal shape, which leads to more time in the shrinker, a delay of care, and more time away from work.
Ideally, prosthetic cases receive specialized management from the earliest possible moment. However, an independent managed care CPO can enter the case at any stage to improve care and reduce costs, as evidenced in the microprocessor leg case described earlier.
Pre-adjudication bill review also introduces a significant cost savings opportunity, especially if the case has not been overseen by an independent managed care CPO. A specialist can tell if a less expensive device will work as well or better than a high-priced recommendation. The independent managed care CPO can conduct peer-to- peer review to discover any issues driving the provider’s selection decision and work with them on the most appropriate and cost-effective solution.
Then, there are the unfamiliar billing codes. There are literally thousands of HCPC codes, and most claims representatives do not work with them often enough to understand what they mean or if a quote is priced correctly.
It’s important to watch for “other or unlisted” codes that have no description or price associated with them. Providers can assign any price they choose to these codes and because “other or unlisted” codes are exempt from state fee schedules; these are typically high dollar codes. It takes an experienced CPO who understands the products and their normal costs to detect highly inflated estimates.
Fortunately, amputations are relatively rare and most injured workers can recover well and return to work within four to six months. Yet, these claims are fraught with cost drivers and it requires specialized care and management to achieve good physical outcomes and avoid unnecessary overpayments.
About Jan Saunders
Jan A. Saunders is a nationally certified prosthetist/orthotist with more than 40 years’ experience. In addition to providing clinical oversight of HomeCare Connect’s prosthetic-orthotic program, which includes peer-to-peer consultation and bill review, Saunders conducts continuing education programs, participates in carrier settlement planning discussions, and provides expert testimonies and depositions.
He began his career as a prosthetic technician before attending Northwestern University in Chicago and New York University’s School of Medicine prosthetic and orthotics program. In addition to treating injured workers over the years, he owned and operated several P&O companies that were later sold to publicly traded companies. Most recently, he was the President and Chief Clinical Officer of one of the largest multi-state, multi-clinic orthotic and prosthetic providers in the United States.
About HomeCare Connect
HomeCare Connect is a national ancillary company in workers’ compensation that specializes in home health, durable medical equipment, home modification services, and prosthetic and orthotic (P&O) services. The P&O services include a credentialed practitioner employee, national network of credentialed providers, a specialized prosthetics and orthotics 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 18,000+ credentialed and directly contracted provider network — to its highly experienced clinical staff who coordinate everything related to care, modifications, 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.
HomeCare Connect is a WorkCompWire ad partner.
This is not a paid placement.