A Call to Action
December 2013 Issue
Surviving the Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractor (RAC) lower-limb prosthetic claim audits is about documenting the patient's desire to ambulate, the medical necessity for a prosthesis, and the patient's potential functional K-level.
Several events have led to the current circumstances confronting the profession. Among these was the introduction of the five functional K-levels CMS defined without also issuing a standardized process to determine them. Another key event was CMS' August 2011 "Dear Physician" letter that defines a physician's responsibilities in determining and documenting the medical necessity for a prosthesis and the patient's potential functional K-level. Yet a significant percentage of physicians still have not been adequately documenting medical necessity for prostheses or functional levels for their patients.
We need to advocate for the following changes:
- CMS should immediately cease all prosthetic RAC Audits for services to Medicare beneficiaries.
- Working with appropriate professional organizations, CMS should develop and issue a standardized and objective process to be used by physicians and prosthetists to determine an individual's potential functional K-level.
- Medicare claim audits for prosthetic services should be suspended until CMS verifies that physicians are complying with CMS documentation requirements.
You should take the following steps to ensure that your concerns are heard and acted on:
- With every response to a RAC audit, you should include a cover letter stating that
you are responding under protest for the following reasons:
- CMS has never provided a standardized and objective process to determine an individual's potential K-level accurately.
- As evidenced by your frequent inability to obtain supportive documentation from your amputee patients' attending physicians, you feel that CMS never verified that physicians both understood and have been following the documentation requirements set out in the 2011 "Dear Physician" letter.
- It is unreasonable to base reimbursement for prosthetic services for Medicare beneficiaries solely on physician-generated documentation.
- Contact your local Small Business Administration (SBA) district office. Meet with representatives and explain to them what is happening with the RAC audits and how they are adversely affecting your business.
- Visit SBA's website and locate the Federal Agency Comment Form under its Office of National Ombudsman (ONO). Fill out and submit one of these comment forms expressing your concerns about what CMS is doing with RAC audits.
- Write to your state's U.S. congressmembers about this matter.
- Assist in the effort to collect objective input from prosthetists and physicians regarding CMS' documentation requirements for prosthetic users via two online surveys, the results of which will be submitted to CMS. Prosthetists may visit www.oandp.com/link/243 to complete the survey. Refer physicians to www.oandp.com/link/244 to complete the survey.
As prosthetists, we are part of a small profession, and that makes it imperative that we communicate our issues with a unified voice. There is strength in numbers, and our livelihoods depend on it, so speak out and be heard.
Peter Seaman, CP, CTP, a graduate of Century College, White Bear Lake, Minnesota, works for Independence Prosthetics-Orthotics, Newark, Delaware. He can be reached at