Reprinted with permission from Amplitude Magazine
Your prosthetist has every right to fair compensation for his/her time, effort, and expertise. And you, the patient, have every right to a prosthetic solution that a) you can afford, and b) equips you for a healthy, happy life.
Not many people would disagree with either of these statements. But the current system for buying and selling prosthetic devices seems designed to impede both objectives. As we described in Amplitude‘s recent look at the dysfunctional consumer market for prostheses (“Playing the Market,” in the March/April edition), it’s nearly impossible to parse the cost factors underlying the price tag of a given device. That leaves amputees unable to assess value, weigh options, and shop around for the best deal they can get—which, in turn, breeds frustration, cynicism, and feelings of helplessness.
Many prosthetists share those feelings. They can never be sure what they’re going to be paid because of the complexities and opacities that are baked into the healthcare system. This dynamic weakens both the buyer and the seller—neither stands on firm ground. It’s not a recipe for mutually satisfying transactions.
“A lot of insurance companies look for ways to pit the patient against their prosthetist,” says Jeff Brandt, who saw this happen routinely during nearly 20 years in practice at Ability Prosthetics & Orthotics. That’s part of a larger trend in US healthcare, in which (as we described last year) large organizations routinely force front-line clinicians to choose between financial necessity and top-quality patient care.
Brandt, now an independent consultant, used to coach his team at Ability O&P to approach patients in a spirit of partnership, on the theory that a united front helps both parties get what they deserve: fair payment for the prosthetist, high-quality care for the patient. Not every clinician is committed to collaboration, but Brandt says patients can be proactive in forging an economic alliance with their clinician.
“I would encourage patients to tell their prosthetist: ‘I want to be engaged in the process,’” he says. “If there are X options for feet and you’re narrowing it down to one or two, ask to be part of that process. Ask how they decided which components to give you and why. Ask for some insights. Sometimes patients will say, ‘Just do what you have to do, because I don’t get any of it.’ My advice is, don’t underestimate yourself. It’s not that complex. Ask them to boil it down for you so that you’re a part of the process.”
At the very least this strategy can yield symbolic wins by fostering trust in the system and diminishing feelings of helplessness. But in many cases, Brandt says, it enables amputees to achieve more tangible gains: a better device, lower out-of-pocket costs, and/or a more fairly compensated (and therefore, perhaps, more attentive) clinician.
Pursuing those outcomes isn’t greedy or pushy; it’s your right as a consumer. Here are a handful of practical areas you might explore with your clinician to make the experience feel more balanced, fair, and transparent.
- Ask for Multiple Service Estimates
If your clinic hands you an estimate and says, “Here’s the best limb you can get, based on your insurance,” don’t just smile and nod. Ask why that’s the best option for you. Ask what tradeoffs (in cost and function) are baked into that scenario, and what the alternatives are. The clinic might have assumed you’ll only consider limbs that are 100 percent covered or that have the lowest possible out-of-pocket, when in fact you might consider investing a little more if it would impact your quality of life. Or perhaps you’re willing to put in an aggressive claim and risk an initial denial, knowing you can always retreat to a cheaper limb if necessary.
It’s reasonable to ask for good / better / best versions of a given device, Brandt says, especially if you’re already on the hook for part of the cost. Simply by presenting you with options, the clinic is inviting you into the process; they’re acknowledging your right to play an active role in the decision making, rather than making the decision for you and saying, “Just trust us, we’re the experts.” Your clinician should be willing to walk you through the pros and cons of various approaches, discuss best-case and worst-case scenarios, and work with you to make a fully informed choice.
- Ask About the Clinic’s Prior Experience with Your Insurer
Unless you have some sort of exotic insurance plan, the odds are your clinic has already dealt with patients—maybe lots of them—covered by the same company. It’s fair to ask about the clinic’s interactions with that insurer. Should you expect an initial denial on your claim? What’s the clinic’s track record of successful appeals after an initial denial? How does the clinic’s appeals department operate, and what steps are involved? What tendencies has the clinic seen from your insurer. Is the company reasonable to work with? Do they use stalling tactics to try to wear you out? Will they actively pit you and your prosthetist against each other?
“Not all clinics support every patient in appeals,” explains Brandt, “and some do it better than others. So don’t assume they’re going to engage in advocacy on your behalf. Ask for something tangible that shows they’re committed to it. Because it can be a long slog. You want to know they’re not just going to file one appeal and then move on.”
- Ask How the Clinic Handles Prior Authorization
Medicare recently shifted to a prior-authorization model for prosthetic devices. “But a lot of private insurance policies won’t issue prior authorization,” says Brandt. “And then some patients say, ‘I guess I can’t get a leg then, because I can’t take the chance that the leg won’t be covered. I don’t have $50,000.’” It can be hard to know whether prior authorization is even available because every insurance company and every plan has its own policies and criteria. There’s a built-in time cost to navigating that swamp, which in itself can act as a deterrent.
However, many insurers will do some kind of prior review. “That’s short of an authorization,” says Brandt. “It’s not a guarantee of payment. But it creates a record. We would never promise their device is covered, but we at least know more about the likelihood that it’s covered. If the patient needs absolute, 100 percent certainty of coverage before they’re comfortable, we would never coerce them. But [prior review] can bring the temperature down a little bit.”
- Ask If You Can Speak with a Peer Advisor.
It’s not out of bounds to ask for a referral to another amputee who’s already been through the mill, Brandt says. Many clinics have patient advocates or peer navigators who can offer knowledgeable but nontechnical input. “Sometimes they’re able to communicate with a client more effectively,” says Brandt. Peer advisors are typically longtime patients of the clinic, so they can offer informed insight about the available technologies, the hazards of insurance and payment, and maybe even the thought processes and habits of your particular clinician.
If your clinic doesn’t have a peer-advising program, you can always reach out to the Amputee Coalition’s peer support program or another patient advocacy organization.
- Don’t Be Afraid to Say, “I don’t get this. Help me understand it.”
Although a clinic should never tell you, “Just trust us, we’re the experts,” the truth is they are experts. They have a vastly broader frame of reference than you do, which enables them to weigh factors and apply analysis that’s outside your realm of knowledge. They may be drawing conclusions that you can’t see—but you can learn to see them.
“It’s easy for a clinician to forget that patients are going through this for the very first time,” says Brandt. “They can’t necessarily connect all the dots right away.” But if you’re not seeing the picture your prosthetist is laying out, ask him/her to connect the dots for you. “You need to go all the way back to your residency days, where you learned to introduce yourself to patients, explain your process, and ask if they have any questions,” Brandt says. “You may have done it hundreds of times, but every patient has to feel like it’s the first time you’ve ever done it—even if it’s four in the afternoon and they’re the last patient of the day.”