Welcome to Health Care POV | sign in | join
Toni Talks about PT Today

We're Not Going to Pay for That Brace

Published July 15, 2014 5:35 PM by Toni Patt

A few weeks ago, a woman was admitted to our facility with a knee injury. She appeared to have ligamentous damage on top of arthritic deformities. She came to us for medical management and antibiotics prior to surgery. Before she was admitted, her orthopedist ordered a KAFO for the involved leg.

I'm not a big believer in KAFOs. In my experience they are bulky and uncomfortable. In this case the woman weighed more than 300 pounds with chronic lower-leg edema, although her skin was intact. This meant the brace required extra reinforcement to be able to support her.

When the brace was finally completed, it cost $2,500. My facility refused to pay for it because that money would come out of their reimbursement. Management stated the brace was ordered before she was admitted and therefore wasn't our responsibility. Furthermore, the brace wouldn't be used until after the surgery, when she would transition to a SNF, so the SNF should pay for it. Naturally the brace company wouldn't release the brace to her without reimbursement.

I wish I could say this was an isolated incident. Maybe the cost is a little more than usual, but it happens all the time. No facility wants to pay for any sort of brace or orthotic. If something off the shelf can't be used, the patient must wait until transferring to the next facility or using Medicare part B if discharged home. Stroke patients do much better with hinged AFOs but they are almost impossible to get.

It almost seems like facilities and insurance companies are practicing medicine. The need is identified. The physician writes the order. Then either the insurance refuses to pay for it or the facility does. Insurances simply say the device wasn't covered. Facilities say the patient can get it at the next level of care, which also won't pay for it. The end result is something deemed medically necessary with a physician's order isn't purchased for the patient.

You Might Also Like...

A Critical Step

When therapy alone can't rectify gait dysfunction, leg lifts and orthotic devices can help.

2 comments

Insurance companies frequently refuse to pay for my childrens medication.  It is a headache and a fight.

Patients are often denied services because a person from the insurance industry has a little power and a title.  They ultimately have the real authority on what kind of services and equipment are delivered.  

The court system works and gets the attention of insurance carriers.  From there, things are settled out of court.  Trust me.

Although I would question the cost of the brace.  It seems a bit much so I can't blame the insurance or the facility for not wanting the bill.  Maybe the maker of the brace has too high of a mark up.  

Jason Marketti July 15, 2014 10:44 PM

"It almost seems like facilities and insurance companies are practicing medicine."

You said a mouthful. It was like this back in the 1980s when I worked at a SCI rehab facility; nothing has changed! It's all about big business and it's not likely anything is going to change.

In my novel series, the very first book starts out with an argument based on this very issue!  It launches the whole saga story. It's too bad you can't control the insurance providers and facilities the way I control my characters and story lines. :)

Mary King, writer July 15, 2014 6:44 PM
Milton FL

leave a comment



To prevent comment spam, please type the code you see below into the code field before submitting your comment. If you cannot read the numbers in the image, reload the page to generate a new one.

Captcha
Enter the security code below:
 

Search

About this Blog

Keep Me Updated