REIMBURSEMENT PAGE
By JOE MCTERNAN
Managing Reimbursement Pain Points
DENIED
Tips for maneuvering same or similar denials, RAC audits, and more
DENIED
E! QU IZ M EARN
2
BUSINESS CE
CREDITS P.18
Editor’s Note—Readers of Reimbursement Page are eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 18 to take the Reimbursement Page quiz. Receive a score of at least 80%, and AOPA will transmit the information to the certifying boards.
“T
HESE ARE THE TIMES that
try men’s souls.” This quote, attributed to Thomas Paine in his 1776 publication, “The American Crisis,” was written during a time when General George Washington’s Continental Army was suffering through several demoralizing defeats and the bitter Valley Forge winter. While a comparison of the daily struggles that O&P businesses face due to reimbursement challenges to those of the Continental Army during the early stages of the American Revolution might seem a bit dramatic, the struggle is real. In today’s O&P climate, reimbursement challenges continue to grow, and they are becoming more difficult to manage. This month’s Reimbursement Page examines some of the more common situations that frustrate O&P providers and offers strategies to help manage the pain points and improve the success of O&P businesses.
16
MAY 2022 | O&P ALMANAC
Same or Similar Denials
When it comes to O&P pain points, same or similar denials are consistently at the top of the list of AOPA member frustrations. Medicare policy does not allow for the provision of replacement items within the items’ defined “reasonable useful lifetime.” In addition to not covering replacement of identical items, Medicare also will not cover items that are considered “same or similar” to items that were previously provided to the patient. Unfortunately, Medicare’s definition of same or similar is rather broad and often creates significant coverage challenges involving treatment methodologies that are considered clinically appropriate. A common example of a frustrating same or similar denial occurs when a Medicare beneficiary is treated with a prefabricated walking boot to stabilize an acute injury and, after a more comprehensive evaluation, it is determined that the patient requires additional treatment with a custom-fitted or custom-fabricated ankle-foot orthosis. Another common example occurs when a patient receives an orthosis to treat an orthopedic condition and several years later is prescribed another orthosis that Medicare considers “same or similar” to treat a new and different condition. In both of these scenarios, the Medicare claim for the second orthosis will almost certainly be denied as a same or similar item.
While same or similar denials cause tremendous frustration, the Medicare appeals process can be used effectively if there is proper documentation in the patient’s medical record that discusses either the need for advanced treatment beyond acute stabilization or the independent nature of the orthopedic conditions that warrant coverage of a second orthosis within reasonable useful lifetime timeframes. AOPA continues to address concerns regarding the overbroad interpretation of same or similar classifications with the durable medical equipment Medicare administrative contractors (DME MACs) and CMS to ensure that Medicare beneficiaries continue to have access to medically necessary, clinically appropriate care.
Reasonable Useful Lifetime Denials
Reasonable useful lifetime restrictions are another source of frustration for O&P providers. While often part of the process that results in a same or similar denial, Medicare claim denials caused solely by useful lifetime restrictions are often a result of unreasonable requirements that an O&P item or component last for at least five years. The Social Security Act states that in absence of guidance from the Secretary of Health and Human Services, the reasonable useful lifetime of an item designated as durable medical equipment, prosthetics, orthotics, and supplies is no less than five years.
