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SWOYERSVILLE — For below-the-knee amputee Brian Bonnerwith, it’s all about quality of life.
Bonnerwith, 46 of Forty Fort, lost part of his left leg due to a popletiel aneurysm three years ago, but to see him walk around, you would never know he wears a prosthesis.
“That piece of equipment,” Bonnerwith said, pointing at his prosthesis, “is everything to a person’s life. I don’t really care about someone at Medicare reviewing a piece of paper.”
Bonnerwith was telling his story at Wyoming Valley Prosthetics and Orthotics in Swoyersville. Dante and Janine Molino are owners of the business, which deals every day with patients who need a prosthesis to return to as normal a life as possible before their injury or accident.
The Molinos are concerned about some new regulations proposed by Medicare that they say will hold up care for patients and delay payment of benefits because of an increase in the amount of forms that must be filled out.
Dante Molino said physicians have always relied on the prosthetist to evaluate the patients and that the paperwork has been minimal. Molino said Medicare is adding more paperwork, another layer of appointments and additional costs and co-payments.
Janine Molino said the new regulations will result in “many more denials.” She said Medicare payments will be made based on basic needs, rather than improving the quality of a person’s life.
As Bonnerwith said, the better the prosthetic, the more functionality patients will have and many would be able to enjoy a more active lifestyle and even return to work.
“Medicare will approve a prosthesis, but they are reluctant to approve one that will have components that result in a higher functionality for the patient,” Dante Molino said.
The Molinos said Medicare in recent years has engaged an accounting firm to review all claims. They said the accounting firm is paid per denial. They said an entire claim can be denied even if only a small error is found, such as a signature or date that is not legible.
With so many denials, Janie Molino said a small business like her and her husband’s will find it difficult to stay open. Dante Molino said Wyoming Valley Prosthetics and Orthotics is the only business of its kind in the region.
Medicare responds
According to the Centers for Medicare & Medicaid Services (CMS), the agency remains committed to providing high quality care to all Medicare beneficiaries, including any beneficiary in need of a prosthesis. A spokesman at the CMS office said both CMS and its contractors have heard the concerns of people like the Molinos regarding access to prostheses for Medicare beneficiaries.
A a result of those concerns, the spokesperson said the Durable Medical Equipment Medicare Administrative Contractors will not finalize the draft Lower Limb Prostheses Local Coverage Determination at this time.
Here is a statement from CMS:
“After a preliminary review of the public comments, CMS is convening a multi-disciplinary Lower Limb Prostheses Inter-agency Workgroup in 2016. The purpose of the Workgroup is to develop a consensus statement that informs Medicare policy by reviewing the available clinical evidence that defines best practices in the care of beneficiaries who require lower limb prostheses.
“The Workgroup will be comprised of clinicians, researchers, policy specialists, and patient advocates from different federal agencies. The Workgroup may also identify areas where evidence gaps exist related to the prescription of lower extremity prostheses, and make recommendations concerning the study designs and outcome measures that best inform patient oriented function, quality of life and service satisfaction in this realm.”
The spokesperson said CMS will ensure there is opportunity for public comment and engagement on the Workgroup consensus statement and any related activities.
Janine Molino said the CMS plan was good news, but she said she remains concerned about what the effect will be on her business if the denials continue.
Dante Molino said denials are appealed and the decisions are reversed about 80 percent of the time. However, he said, the problem is the amount of time it takes to go through the process and receive payment.
“Sometimes it takes years to receive payment,” he said. “How can you run a business that way?”
