In the Medicare Modernization Act of 2003 the United States Congress directed the DHHS to conduct a 3 year study into "fraud and abuse" within the medicare system. In 2005 CMS implemented the program using RAC auditors to try and recuperate money from Medicare suppliers. Part of this program led to strict new guidelines affecting all Medicare beneficiaries. Due to these issues Medicare beneficiaries are finding it more and more difficult to get the orthotic and prosthetic goods they want and need.
The guidelines set fourth extremely strict and objective guidelines for standards and documentation that providers must follow. Included in these guidelines it states that the prescribing doctor's notes must state why the patient needs the particular good. For orthotist's and prosthetist's it is extremely difficult to get doctors to get us those notes. Not only were the doctors not informed by CMS that they must provide this information, but they also are not privy to all the intricacies of the orthotic and prosthetic world. Most doctors know very little about the specifics of orthotics and prosthetics so they are hesitant to write detailed notes stating why patients needs specific componentry. This leaves orthoists and prosthetists in between a rock and a hard place, they know patients need these medical goods but also must be assured they will be reimbursed for them.
Another problem stems from the RAC auditors denying claims based upon small discrepancies in paperwork. A signature from a doctor that is not legible, a date that cannot be read perfectly, or any other number of small problems that often occur can and will get your claim denied. The RAC audit companies are paid on a percentage of savings so for those companies it literally pays to deny medicare beneficiary claims. The search for fraud and abuse has spiraled out of control and patients who need orthotic and prosthetic intervention are the ones paying the price.
Unfortunately until these RAC auditors are reigned in and given more strict guidelines about how and what they can audit orthotists and prosthetists must proceed cautiously. If you have questions about the above information you are more than welcome to contact O'Connor Orthopedic and Prosthetic at 714.635.2650 or contact Medicare directly at 1.800.633.4227