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Feb 4, 2016

My Joel Fleischman Take on Our New Medicaid Form for Orthotics

I am very excited now that our Medicaid program in Arizona will be covering orthotics. Well, not so fast. They will cover it if the following criteria are met:

1. The use of the orthotic is medically necessary as the preferred treatment option consistent with Medicare Guidelines.

2. The orthotic is less expensive than all other treatment options or surgical procedures to treat the same diagnosed condition.

3. The orthotic is ordered by a Physician or Primary Care Practitioner.

The last one is easy and does not need coverage here. The first one can be dissected also, but I will live with it even if the wording is a little off; as in, since when is Medicare the provider of medical guidelines (CMS is an insurance company that pays for a lot of stuff; and does not cover a bunch of other stuff; they provide coverage guidelines, not medical guidelines)

Clause #2 is the ringer here and the reason that I need to express my cynicism towards this document. See, the folks at the Medicaid office sent a completed form back because I did not put an ‘X’ in the box that states:

Prescribed Orthotic Device Is The Most Cost Effective Treatment Option [ ]

They sent it back, via facsimile, with a cover page that stated that without this box crossed off, the patient would not be eligible for the orthotic that was ordered. They list five things that the orthotic needs to be cheaper than in order to be covered: Surgery, Cast Application, Durable Medical Equipment, Pain Medication, and Other. None of this makes sense; nor should your physician be expected to be an actuary.

We order orthotics in our Wound Center. The most common would be a Diabetic Walker Boot to redistribute pressure across the plantar surface of the foot in a patient with a ulcer due to neuropathy. This is actually our second choice for this condition, as a total contact cast (TCC) is always the goal. Due to the conditions of certain patients (including the risk of falls for our elderly), we are often left with a second best choice of ordering the walker boot.

The Medicaid program has full expectation based upon this document that Physicians know the cost of the boot and its comparison to the other choices listed even if they are not applicable. Remember, all boxes must be filled or else the people over on the other side of the fax machine will send it back to you. Let us compare the walker boot to surgery. Certainly, recommending any surgical treatment, even if it is not indicated would be more expensive than most orthotics. I guess we are safe here and can just put that we are trying to avoid an amputation. Is this really necessary?

Next, they want us to compare it to the total contact cast (TCC). As stated above, the TCC is the treatment of choice to heal a diabetic plantar foot wound. I am not Houdini and could not predict how many visits we are going to save [sic], nor would I know the total costs of the cast administrations for both the clinic and myself. The hospital does not share what they get reimbursed by Medicaid for this or any other procedure.

Now they want me to know the cost of the wheelchair or crutches that I did not need to order for this patient. The pain medication section has little to do with the order for the orthotic and since we do not order or administer pain medications in our office, this is a non sequitur.

The public needs to know that physicians are expected to complete these forms in order to get the appropriate treatment for their patients. As in this case, forms are generated that do not make sense and are a waste of our time. In this case, care was delayed another week for this patient because the form did not have an ‘X’. This potentially put this patient at risk for a very poor outcome.