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Published in the O & P Business News, September 1, 2000
Dear Editor:
I’ve read several articles recently regarding L-coding, most recently in the O&P Business News June 2000 and
In Motion June 2000. In these articles the authors, John Michael and Brad Rosenberg both point out the difficulty
of working with the L-code system. John Michael points out “four major problems with the L-codes currently, all
the results of poor administration rather than fundamental flaws in the system.” The four areas are outdated codes,
overlapping codes, confusing official descriptor language and access to L-codes by untrained individuals. I disagree;
the problem with the L-code system is poor administration (people with the power to make decisions but without
any working knowledge of the industry) and a system flawed in design. It was flawed from the start, and to make
matters worse, most of the hundreds of insurance companies and HMO’s that have come along in the last 30 years
have adopted some version of the Medicare L-code system. We invoice over 70 different insurance companies at our
office and all of them use some variation of the L-code system. What about scraping this thing and starting all
over again? How about a billing system that reflects what we actually do?
In my opinion, the following points are the most important billing criteria and reflect more accurately what we
actually do:
* A socket charge with a degree of difficulty factor. For instance, it is generally more difficult to satisfy the
prosthetic needs of a very active 35 year-old farmer than it is a 75 year-old male in a nursing home who spends
23 hours a day sitting down, or were able to actually bill for the amount of time involved with each patient.
* An alignment charge, again with a difficulty factor, for the same reasons as above.
* Componentry. A list of the exact components used as identified by the manufacturers catalog number. Not the current
convoluted verbal description as presently used in the L-code system and what John Michael describes as a brilliant
decision by AOPA to come up with in the first place. Bunk.
The L-code system is vague and open to interpretation. What sense does it make to bill for a “description” of an
item when you could bill for the item exactly. The L-code system must be interpreted and interpretations can be
challenged. More over third party payees may challenge these “interpretations” with the resultant legal pitfalls
and ramifications. Wouldn’t it be simpler if you billed for exactly what the person received? For example, if you
put a Century 22 knee on a prosthesis--bill for that specific knee. The way it is now two facilities could make
the exact same prostheses and come up with two separate amounts. That’s nonsense. Now I think I understand how
the Defense Department bought $400 hammers and $800 toilet seats.
* The last point I have to make is so obviously ridiculous that I am amazed and ashamed that I even have to mention
it.....free work! People in this industry do work over through no fault of our own for free. We are expected to
do this by both patients and third party payee’s. Whether it is time, material or the actual exchange of componentry,
we are expected to comply with the wishes of the amputee sometimes weeks or months after they have received their
prosthesis. What other profession would do this? As an example, Mrs. Jones receives a prosthesis wearing a five-ply
sock. Four weeks later she’s into an eight-ply, and perhaps been to a Physical Therapist who thinks she should
be wearing a three-ply. She returns to voice her complaint. We are faced with solving a problem we didn’t cause.
There are two options; do nothing by sending her out the door (probably quite angry) or redo the prosthesis at
no charge. Due to the inherent problems of being an amputee and dealing with atrophy and swelling this problem
is repeated over and over. Three weeks later she doesn’t like the foot either. Now what? The paradox here is that
the insurance company will not pay me to re-do it, but if she goes to another facility they will probably recommend
she get a new prosthesis and the insurance company will probably pay for it. At what point are we relieved of these
responsibilities? Now think real hard and try to come up with another profession from cranial surgery to carpentry
that would be expected to do as much work for free as we do.
I don’t disagree that some pro-bono work is acceptable to many professions, however we do far too much. The reasons
are a poorly structured fee schedule, insurance’s that have no idea what we actually do and our stupidity for letting
people who don’t know what we do, tell us what to do. Are we dumb or what? I am amazed at AOPA and its members
voicing complaints about a problem that they created or certainly helped create in the first place and advocating
its continued use. If it was up to me I’d dump it and start over again.
While on the subject of AOPA, how did they become the anointed leaders of our industry in the first place? They
sure have done a lot of Congressional lobbying on behalf of their members. There are other valid opinions that
are not heard in the halls of Congress. Too bad. Apparently unless you’re a member of a PAC your voice is too faint
to be heard. Congress may listen to the voice of the people they just hear better when the voices ride the wings
of hundred dollar bills. Interestingly, I’ve written dozens of letters to Congressmen over the past seven years
expressing my opinion of the dangers of giving too much credence to the opinion of groups like AOPA. In return
I received a single response from Congressman Peter Stark. Thank you Congressman Stark.
AOPA’s efforts to restrict to its members the exclusivity of providing O&P services has a colorful history
as pointed out by a 1977 Federal Trade Commission investigation of ABC, AOPA and AAOP (file number 771 0022). The
investigation centered around price- fixing and other non-competitive practices. The FTC found that AOPA “assiduously
sets up barriers to non-certified individuals within the industry.” Their claim that their certifying body, ABC,
assures the public of competent skilled prosthetists and thus protects the public is contrary to what the FTC found.
It is never in the consumers best interest when a single group controls an industry.
The majority of prosthetists are ABC certified, however, based on the results of the survey we published in the
O&P Business News (January 15, 1999) 54% of the O&P facilities bill for the device before the services
are rendered; fifty-five percent will accept 80% as payment in full when a co-payment is due. Essentially making
the prosthesis free to the amputee. Both these practices are illegal, but apparently common. No wonder in the same
survey 64% of the amputee respondents said they were on a never-ending search for the next best prosthesis. Amputees
satisfaction with the industry is poor as demonstrated by a rating of 5.6 on a scale of 1 to 10 (10 being best).
When I was in school a grade of 56 was flunking.
Somewhat surprisingly fewer and fewer of the practicing professional O&P providers can actually make the appliance
they are providing. We have even coined a new phrase “clinician.” Webster’s Dictionary defines clinician as “a
doctor, psychologist, or psychiatrist specializing in clinical studies or practice.” What is a clinical prosthetist?
A recent published definition of a prosthetist states: An allied health professional specifically trained and educated
to provide or manage the provision of a custom designed, fabricated prosthetic device. The key point is one no
longer has to provide, he only has to manage. I suspect based on some experience that there is a growing number
of certified O&P providers who in fact cannot make the product they are providing due to lack of technical
abilities. While attempting to hire a CPO for my company I was stunned that not one of the several individuals
I interviewed was willing or able to take an amputee from casting to final delivery and follow-up of a prosthesis
all by themselves. And these are the same people who essentially want everybody else out of the business. All of
this spends healthcare dollars without direct benefit to the patient.
To support my view in the July 15 issue of the O&P Business News the California Health Association, (CHA) opposes
O&P licensure because the association felt that only certain healthcare professionals should be licensed. Those
who should be licensed CHA said “are those few occupations where quality of patient care is enhanced by licensure,”
such as medical doctors and nurses. On the other hand, CHA called O&P practices essentially technical in nature.
CHA also complained “licensure would create unnecessary bureaucracy and an artificially tight job market, raising
medical care costs.” I agree.
We are essentially technicians because we do not use scientific information to determine what prosthetic components
to provide amputees. We simply do not have numbers to substantiate that component A is best for a geriatric amputee
and component B is best for a very active amputee, etc. Who said a narrow M-L socket holds the femur in place better
than a quadrilateral socket or a Flex-foot is better for a active amputee than a College Park foot. Where was this
information scientifically analyzed and where was it published? We base our decisions mostly on subjective information.
No artificial limb can help an amputee perform beyond his potential.
Most prosthetist/orthotists are good hard-working individuals who take the responsibility to their clients seriously.
The current system is not fair to providers, their clients, or the insurance companies. It can and should be changed.
Michael Love
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